Why insomnia rarely travels alone

If you've been struggling with sleep for more than a few weeks, you've probably tried a long list of things. Cutting caffeine. Going to bed earlier. The 4-7-8 breathing technique someone recommended on Instagram. A new pillow. Melatonin. A sleeping pill from your GP. Some of these may have helped a little — most probably didn't.

This is because for the vast majority of patients I see at the clinic, insomnia isn't the underlying problem. It's a passenger. Something else is the driver, and treating just the sleep — without addressing what's actually causing the sleep loss — is a bit like trying to fix a leaking ceiling by putting a bucket underneath. It's not wrong, exactly. It just doesn't solve the leak.

What we look for first

When someone comes to me complaining of poor sleep, my first job isn't to write a prescription. It's to figure out what's actually keeping them awake. Three things are involved most often:

1. Anxiety

Anxiety and sleep have a particularly cruel relationship. The mind races as soon as your head hits the pillow. You can't stop thinking. You worry about not sleeping, which makes it harder to sleep, which makes you worry more. Many of my patients describe lying awake from 1 to 4 in the morning, going through tomorrow's tasks in vivid detail.

If your sleep difficulties involve a busy mind that won't switch off — anxiety is probably your driver. Treating the anxiety usually rescues the sleep. Treating only the sleep rarely rescues either.

2. Depression

Depression has a very specific sleep signature: early morning awakening. Patients often fall asleep without too much difficulty, but find themselves wide awake at 3 or 4 am, mind heavy, unable to drift back. They're tired, but rest doesn't come.

This pattern is so characteristic that when a patient describes it, depression jumps to the top of my list — even if they don't otherwise feel "depressed" in the way they expect to. Many of these patients are surprised to learn they're experiencing depression at all.

3. Alcohol

This one is hard to talk about, but it's important. Many patients come to me with chronic insomnia who are also having one or two drinks every night to help them sleep. They've often been doing this for years.

Alcohol does help you fall asleep faster — but it severely fragments the second half of the night. It suppresses REM sleep. It increases nighttime awakenings. The longer you use it as a sleep aid, the worse your underlying sleep gets. Cutting alcohol almost always improves sleep within 2-3 weeks, even if it temporarily feels worse for the first few nights.

The two questions I ask early in any sleep consultation: "What's on your mind when you can't sleep?" and "What are you doing to try to get to sleep?" The answers usually tell me more than any sleep tracker would.

The other passengers

Beyond these three, there are several less common but important contributors:

• Sleep apnea — often missed, especially in non-overweight patients. Look for: snoring, gasping awake, daytime sleepiness despite "enough" hours in bed. A sleep study can clarify quickly.
• Thyroid problems — both overactive and underactive thyroid disrupt sleep in different ways. A simple blood test rules this in or out.
• Chronic pain — backaches, joint pain, headaches that worsen at night. Treating the pain often resolves the sleep.
• Restless legs syndrome — uncomfortable sensations in the legs at night. Specific medications help.
• Medication side effects — certain blood pressure medications, steroids, and even some "sleep aids" disrupt sleep architecture.

Why the standard advice often falls flat

Generic sleep hygiene advice — no screens, cool room, regular bedtime — is genuinely useful, but it's only useful when sleep is the actual problem. If your sleep is broken because of untreated anxiety, no amount of bedtime herbal tea is going to fix it.

This is also why standard sleeping pills frustrate so many patients. They knock you out, but they don't address the underlying issue, and over time most of them stop working as well as they did initially. Many also create dependence — the very common Alprax / Restyl / Lonazep family of medications is particularly problematic this way. We use them sparingly and short-term, never as a long-term solution.

What good sleep treatment actually looks like

The gold-standard treatment for chronic insomnia is something called Cognitive Behavioural Therapy for Insomnia (CBT-I). It has stronger evidence than any sleep medication. It involves several specific techniques: consolidating your sleep into a tighter window, retraining your association with the bed, addressing catastrophic thoughts about sleep, and structured relaxation.

It's not magic. It asks for some discipline — usually for 4-6 weeks. But the results last, in a way that medications don't. We combine CBT-I with treatment of any underlying conditions (anxiety, depression, alcohol use, thyroid, sleep apnea), and most patients see meaningful improvement within 6-8 weeks.

What to do if this sounds like you

Three things, in order of importance:

1. Be honest with yourself about the passengers. If your mind races at night, anxiety is probably driving. If you wake at 3 am unable to return to sleep, consider depression. If you're drinking to sleep, that's worth looking at.
2. See a psychiatrist, not just a GP, if it's been more than 3 months. Chronic insomnia is a psychiatric specialty. The evaluation is more thorough, and the treatment options are wider.
3. Don't accept "just take this pill" as the only answer. Effective insomnia treatment almost always requires more than that.

Sleep is recoverable. Most patients I see who've been struggling for years are surprised at how much improvement is possible — once we figure out who's actually driving.